30667 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING-BLEurRICAL PERMIT NO. /�
Bi
DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAI. O 66 y�
BUILDING PROJF.CI'IDEN'OFICA'PION V N
' BUILDINGA�RS �S: � SANITARY NO, APPLICATION SUHM�AL DATI
lo6
15
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OW S N MEPI ONE [ GVryNA L. O:
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CONTROL If
•.�\RC ITECAENGIR: LIC NO: ADDRESS: ❑
CONTACT: A PHON': • BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) NL ECr PLUMB MECH
c.11�sMNN+ "✓a V ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT Fs.
Hereby arRrnt rant 1 am Han,ed ander rrnvi,ion,or enam,t 9 a'mmrencing JOB DESCRIPTION
�d'Z with Section lOOgof Division3ofthe Bu,inessend Pmfessinnn Code,and mylicenne is RESIDENTIAL'
I�-OO infull force and effect. PERMIT'ISSUANCE
C4 m_ ❑SFDW'L ❑KITCHEN REM1fODEf.
scUzt) License Class Lie# APPLIANC&S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
HQ L Data Contractor
,iZiV ARCHEI F-CTS DECLARATION PANELS ❑MUI.TI-UNIT ❑STRUCTURAL.
Z C tt2 2 l understand my dam,hull be u,eJ as Public records MODIFICATION
O Z-C UPT0200 AMPS I ❑INTERIOR ❑CHIMNEY REPAIR
ra onE-W Liveried Pmfessioml 201-1000AMPS IMPROVEMENT
C �Z OWNER-BUILDER DECLARATION m OVER III(NIAA1Pti QHAfH REMODEL/REPAIR DEMOLITION
6' <a I hereby oilirm that 1 ant exempt tram the Contractor's License Law lar the +�(]l
seax 6 U following rtason.(Section 7031.5.Business wd PoofeWin,Cvwx:Any city or county OTHER
I+131+-y which restores, mit mw
a perm cact,alter.improve.demolish repair any,wure SIGNS IiLECfRICAI.ct
,B
poor o its issuance,also requires the applicant lir such permit t)file a signed statement SPECIAL CIRCUITIMI
that he is lamised pursuant o the proviviun,of the Contractor's Licence Law(Chapter 9
1`1800 (commencing with Section 70[0)of Division 3 ofthe Business and Profession%Code)or TEMP.MET ER OLE INST. COMMERCIAL•
a a o that he is exempt thcrelmm amt the biers for the alleged exemption.Any viulaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
=y
Section 70315 by any applicant for a pmenit subjects the applicant to a civil penalty of POWER DEV S ❑TENANT FOOD SERVICE
Sqnot more than rise hundred dollars(55001
❑ I,as owner of the propasy.or my employees with wages a,their sole cmnpanmtion, IMPROVEMENT
1.., will Jo the work,and the svvmure is not intended or offered for sale(Sec.WHA,Bminea., GOPHER
1`1 and Professions Cole:The Contractors License law doe,not apply to m owner of OUTI. S-SWITCHES-FIXTURES
properly who builds or improves Ncrcon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NE RESIDENTIAL ELECfR SQ
sale.if,however,the building or improvement is,oid walainom, totif,ontpled'n,the S FtI PIf110R AREA $ISQ.fT.
Her-builder will have the burden of proving that he did not build or improve for put- i [[J/
you of sole.). TOTAL:
E3 I,as owner of the pmfvoy,am exclusively contracting with licensed contractors to EC 2 1996
construct project(Sec.7f W.Business and Professions Cod,The Contractor's Li-
c Luw docs not apnly m anowno,of p olmmy who buihhor improves thenen.and QTY. PLUMBING PERMIT FEE
who contracts for such pmjects with a contncon(s)licensed pursuant to the Convector's f,1(�
License law. PERMIT ISSUANCH Uf UUt IINU
❑Tom exempt under Sec. ,H&PCfonhis memo
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner [)am I
WORKER'SCOMPENSATION DECLARATION following
BACK PLOW PRO'FIiCI'.DEVICE
1 hereby illmaimuna penalty of ofCoyoneof the fnsuming orker'lom:
❑Ihave andwillmain mi nation 37om of the Labor
ode,iff for the Worker's Compcn- DRAINS-FLOOR.HWEAREA.COND. STORIP_S TYPE.CONSTRUCTION
scion,as provided Inr by Section PIXI of the Labn Code,for the performance of the
work fur which this pernat is issued. FIXTURES-PER TRAPi ( �t. /ie•/.
El 1 have and will maintain Workers Compensation Insurance,as required by Section N ✓I_I �//
3700mdo Labor Code fortheicformance of the work hthOCC
GROUP whicis permit is ramal. GAS-EA.SYSTEM-1 INC.J OUT - S OC GROUP APN
My/ Cartier:r��CpaV cone Polmy Nu.yjhl L '�A K/A GAS-EA.SYSTEM-OVER i .AI
CERT FI EX PTION FROMWORKERS' R{CL
COMPENSATION INSURANCE GREAS191NDUSTRI,W EINTERCEPTOR BUILDING DIVISION FE[J
(Dissection neednotbecompleted ifflofeemit isforonehundraldolliers(S100) GREASETRAP
or Icssl PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued.I shall SEWER-SAN ARY-STORM EA.2fq F4.
nut employ any raison in any ntan,,,u to ut basome,abjecuo the Workerx Camper. ENERGY FEC
Z ration law.,of California.Date WATER li ERW/VEN VELECfR GRADING FEE
Z 2 Applicant
Uri NOTICE TO APPLICANT:If,after making this Certificate of Exctnpticn.you should WATE SYSTENITREATING
became subject m the Worker's Compensation provisions of the Labor Cole,you must SOILS PEE ./
W ✓,.�, 4mbwith simply wit i,mli provision,on his pmanh xhall he devoted revoked. _/H R SERVICE
CONSTRUCTIONLENDWGAGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
ti
7 Z Ihertby affirm the free
isisaconstruction lending agency fur the pedomanre of Date RecciptN
� . the work Is which this permit is issued(See YN7,Civ.C.)
f" Under,NameTOTAL:
V Lender',Addrc,s TOTAL:
D.I 1 certify that 1 have read this applicaim amt,tam the the above information i, BUILDING FEE
Ncorrect l agree to comply with all city and county ordinances andaate laws relating m QTY. MECHANICAL PERMIT FE
C.) Z buildingsmmctknomd herchy amhorm representatives ofthis city Jeemer upon the SEISMIC FEE
abovcta
ntnioned property for inspection purposes PERMIT'ISSUANCE'
(We)agrer to xme.indemnify and keep harmless the City of Cupertino ainst
gaELECTRIC FEEL
moms,costs and expenses which may in anyway accrue against said City ALTER OR ADDTO MECH.
inctmsequ cofthegramingofthi permit. PLUMBING FEE
APPLICA fUNIIERST NfS At D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IBM)CAM) I MECHANICAL FEE
SOURCE 'FG 11 11 )
1AIR HANDLING UNIT(OVER I0.000CPM) CONSTRUCTIONTAX
Si ammpp
o(AlicanifConwctor Date EXHAUST HOOD(W/UUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
...our furore maddiogocetivol,mma,handle hmanlousneecou HEM INC,UNIT(TO 100,000 BTU)
as def ned by the Cupenin,Municipal Code Chapter 9.12,and the Health and Safety
Cod,.Section 255320)? HEATING UNIT(OVER 100, TO
❑Ye, E]No VEM'ILATION FAN(SIN RESIDI PAID
Will thea applicant or future hui Wing mvu t use equipment or device,which Du0. R
pP b pan Area
BOILER-COMP(3H RIon,olNI BTU)
mit he imus air contaminenL,as refined by the Bay Am Air Quality Management Al.
District? BOILER-COMP VER100.000BTU)
CI yes 0N
I have read the hazvdue,menialsmqu.n.•ments under Ch,her 6.95n1'the Cali- AIR CONI;?641:14 ISSUANCE DATE
fomia IImIN&Soley Code,Sections 25505.25533 and 255}1.1 understand that if the NEW SIDENTIAL MECH. SQ.FI'.
building does not curmntly have o tenant.that it is my responsibility to unify the occupant
ofthe requi¢metna which must be met prior to issuance of a Cenilicae of Occupancy.
Owner or aoduceed agent (late TOTAL: ISSUED BY:
OFFICE